THE IMPACT OF QUARANTINE ON 

MILITARY OPERATIONS 

by 

Robert I. Miller 

The Counterproliferation Papers 

Future Warfare Series No. 31 

USAF Counterproliferation Center

Air University 

Maxwell Air Force Base, Alabama 

The Impact of Quarantine on 

Military Operations 

Robert I. Miller 

August 2005 

The Counterproliferation Papers Series was established by the USAF 

Counterproliferation Center to provide information and analysis to assist 

the understanding of the U.S. national security policy-makers and USAF

officers to help them better prepare to counter the threat from weapons of 

mass destruction. Copies of No. 31 and previous papers in this series are

available from the USAF Counterproliferation Center, 325 Chennault 

Circle, Maxwell AFB AL 36112-6427. The fax number is (334) 953-

7530; phone (334) 953-7538. 

Counterproliferation Paper No. 31 

USAF Counterproliferation Center

Air University 

Maxwell Air Force Base, Alabama 36112-6427

The Internet address for the USAF Counterproliferation Center is: 

http://www.au.af.mil/au/awc/awcgate/awc-cps.htm

Contents 

Page 

Disclaimer................................................................................................... ii

The Author................................................................................................. iii

I. Introduction.........................................................................................1 

II. History of Quarantine .........................................................................5 

III. SARS ..................................................................................................7 

IV. SARS - International Lessons Learned.............................................11 

V. Quarantine Laws...............................................................................19 

VI. Quarantine Policy .............................................................................23 

VII. Lessons Learned from Bioterrorism Exercises.................................25 

VIII. Military Operations and Quarantine .................................................29 

IX. Recommendations for Commanders.................................................31 

X. Conclusion ........................................................................................39 

Notes..........................................................................................................41 
ii 

Disclaimer 

The views expressed in this publication are those of the author and do 

not reflect the official policy or position of the U.S. Government, 

Department of Defense, or the USAF Counterproliferation Center. 
iii 

The Author 

Dr. Robert I. Miller, Colonel, USAF, MC is the Commander of the 

48th Medical Group at RAF Lakenheath in England. As Commander, he 

is responsible for the largest Air Force medical facility in Europe. The 

48th Medical Group has primary responsibility for the force health 

protection and direct medical care of two major wings locally and the 

referral care of more than 35,000 American forces and associated 

personnel in the United Kingdom. Col Miller has a Masters Degree in 

Strategic Studies from the Air War College at Maxwell AFB, AL. He is 

board certified in both general pediatrics and developmental-behavioral 

pediatrics by the American Board of Pediatrics. He is also a Certified 

Physician Executive by the Certifying Commission in Medical 

Management. 

The Impact of Quarantine on Military Operations . . . 1

The Impact of Quarantine on 

Military Operations 

Robert I. Miller 

I. Introduction 

The single biggest threat to man’s continued dominance on 

the planet is the virus. 

–Joshua Lederberg, PhD, Nobel Laureate 

The above quote precedes the opening battle scene in the 1995 

Warner Brothers hit movie Outbreak which graphically depicts the 

problems the Department of Defense (DoD) may face in preventing a 

global meltdown secondary to the uncontrolled spread of a deadly 

biological agent. Although fictional, this technothriller was based in 

scientific possibility and used the highly virulent Ebola virus as the model 

for a rare killer virus from the jungles of Zaire, which mutated from a

contact to airborne strain and ultimately took hold in a small California 

community. With no treatment or vaccine immediately available, the 

military was ordered to institute mandatory isolation and quarantine as the

last hope of containing the virus. 

The film provided a classic example of how terror and panic can 

result if quarantine is implemented inappropriately, whether secondary to 

an act of bioterrorism or in response to a naturally occurring infection that 

is spread by chance as occurred in Outbreak. The film’s producer, Arnold 

Kopelson, stated that “the most frightening aspect of the story is the real 

potential of such a contagion developing in the real world at any given 

moment.”1

 The recent Severe Acute Respiratory Syndrome (SARS)

pandemic clearly substantiates this fear. In the Global War On Terrorism

(GWOT), the threat goes beyond naturally occurring bacteria or viruses, 

and the military must be prepared to prevent a replay of the initial battle 
2 . . . The Impact of Quarantine on Military Operations

scene from Outbreak where the field surgeon states, “men wounded in 

battle we can deal with, but this strange disease...thirty men dead

yesterday...eighteen the day before...”2

 In dealing with an enemy that

attacks at the microscopic level, an installation commander must

understand that the contagion will not be stopped by the perimeter fence, 

and sustained operations are dependent on an aggressive, time-sensitive 

response. Ideally, immunizations and chemoprophylaxis for those

exposed will be available assuming early identification of a known agent 

with treatment options, however, this may be unrealistic in certain 

settings. When this is not possible, quarantine is at the heart of an 

effective disease containment strategy in the war against bioterrorism 

providing the military with the best chance for preparedness and response 

against any biologic contagion. 

As stated in the 2004 United States Air Force Counter-Chemical, 

Biological, Radiological, Nuclear, and High-yield Explosive (C-CBRNE)

Master Plan, the Air Force must be able to survive, fight, and win in a

CBRNE environment. Quarantine is an effective public health measure 

that can impact two of the five C-CBRNE pillars discussed in this

document to include passive defense and consequence management.3

The goal of quarantine is to enable forces to survive, operate, and

ultimately restore essential operations in a biological-contaminated 

environment, while maintaining disease containment. The importance of

quarantine as a disease outbreak control measure is supported by recent 

historical experience, and much can be learned from a better 

understanding of the 2003 SARS pandemic. Mandatory quarantine also 

raises concerns about loss of civil liberties. It is beneficial to fully 

appreciate the legal issues and policy guidance that come into play in 

regards to bioterrorism preparedness and response. 

The anthrax letters of 2001 provided the impetus for the Model State 

Emergency Health Powers Act that served as a key framework for states in 

reviewing their outdated quarantine laws, and these laws have been put to 

the test in multiple bioterrorism exercises throughout the United States. 

Although anthrax served as the trigger, it should be noted that quarantine

of potentially exposed personnel is effective for diseases such as smallpox 

or plague that is spread from person to person, but it is not helpful for

other diseases like anthrax that are not communicable. The DoD has also

been active in updating guidance regarding quarantine implementation, 
The Impact of Quarantine on Military Operations . . . 3

however, the operational implications for using quarantine or other 

restriction of movement measures are not well described. 

The purpose of this paper is to fully define the role of quarantine as a 

battle-tested public health strategy and its potential impact on military

operations in the United States Air Force (USAF). The primary emphasis 

will focus on how a commander can carry out effective operations while

adhering to quarantine requirements during the initial 72-hour period 

following the realization of an outbreak. Quarantine may not be

appropriate in all cases, however, this may not be clear until a definitive

diagnosis is known, which takes time. Unfortunately, time is not on the 

side of a commander forced with making a decision on how best to 

respond to an emerging disease outbreak. 

From a medical perspective, the initial 72-hour period was selected as 

a reasonable, conservative window for intervention based on recent 

bioterrorism exercises. This period of assessment will most likely precede 

arrival of additional support and formal identification of the involved 

agent, especially at an overseas installation. Actions taken during this 

critical period will determine if a commander has any hope of containing 

spread after a biologic attack. Disease containment challenges faced by a 

commander at an overseas installation are greater than in the Continental 

United States (CONUS) based on limited resources with a higher level of 

threat, so recommendations will focus on quarantine implementation in the

overseas environment. That being said, many of the recommendations 

regarding timing of quarantine and sustainment options will be applicable

regardless of the facility location or source of the biologic threat. 

The Impact of Quarantine on Military Operations . . . 5

II. History of Quarantine 

The formal practice of quarantine has a long history dating back to 

fourteenth century Italy when ships arriving in Venice from infected ports 

were required to sit at anchor for forty days before landing to protect 

coastal cities from plague epidemics.4

 United States history involving 

quarantine was sporadic and implementation was primarily at the state 

level until 1878 following the passage of Federal Quarantine Legislation 

by Congress secondary to yellow fever epidemics, although control still 

remained with state public health officials.5

 It was not until 1892 with the 

arrival of cholera that this law was reinterpreted to allow the federal 

government more authority in imposing quarantine, which resulted in 

questionable targeting of certain ethnic groups as occurred with Jewish 

immigrants in New York.6

 Quarantine boundaries were also enforced 

around Chinese residences and businesses in San Francisco in 1910 after 

the discovery of plague.7

The 1944 Public Health Service Act established the federal 

government’s authority over quarantine.8

 Federal responsibility was 

transferred to what is now known as the Centers for Disease Control and 

Prevention (CDC) in 1967, and the Division of Global Migration and 

Quarantine now has authority to prevent interstate spread of disease or

introduction of diseases from foreign countries as per U.S. Code 264 Title 

42.9

 Communicable diseases for which federal isolation and quarantine 

are authorized are clarified in Executive Order 12452 and include cholera, 

diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, and 

viral hemorrhagic fevers.10 SARS was added to this list in April 2003 as 

per Executive Order 13295.11

In addition to quarantine, isolation is another option for imposing a 

restriction of movement. Isolation refers to separation of persons who 

have a specific infectious illness from those who are healthy to stop the

spread of that illness.12 In contrast, quarantine involves the separation and 

restriction of movement of persons who are not yet ill, but have been 

exposed to an infectious agent and therefore may become infectious.13 

Quarantine may be voluntary or compulsory and although implemented 

for the common good, it results in the restriction of some personal 

liberties.14 Although isolation requirements are frequently straightforward 
6 . . . The Impact of Quarantine on Military Operations

and accepted by society given the presence of active disease, differing

opinions exist regarding appropriate use of quarantine secondary to 

concerns over loss of civil liberties. Quarantine of individuals is only 

effective for diseases that have the potential for communicability from

person to person such as plague, smallpox, viral hemorrhagic fevers, 

influenza, and SARS. 
The Impact of Quarantine on Military Operations . . . 7

III. SARS 

The kinds of things we are doing for SARS we can 

anticipate we are going to do again and again. 

–Dr. Julie L. Geberding15

Dr. Geberding, Director of the CDC, made the above statement about 

SARS while testifying before the Senate Committee on Health, Education, 

Labor and Pensions on April 29, 2003.16 SARS was responsible for the 

first pandemic of the twenty-first century after quietly emerging in China’s 

Guangdong Province in November 2002 and dramatically spreading to 27 

countries on five continents in 2003.17 On March 12, 2003, the World 

Health Organization (WHO) issued a historic global alert for this

previously unknown deadly disease which resulted in aggressive 

containment efforts that brought an end to the pandemic in July 2003, but 

not until more than 8,000 cases and 780 deaths had been reported to 

WHO.18

There are many positive, basic public health lessons to be learned

from SARS. Measures of surveillance, infection control, isolation, and 

quarantine were directly responsible for bringing this new deadly disease 

under control. Quarantine was implemented on an unprecedented scale in 

China, Canada, Hong Kong, Singapore, Taiwan, and Vietnam, resulting in 

numerous challenges for public health officials and policy makers given 

the broad impact of this strategy.19 Quarantine was not a complete success

in all jurisdictions secondary to a questionable implementation strategy in

China and Taiwan, but these cases were the exceptions. It is from these 

experiences that the military can gain valuable insight regarding the use of 

quarantine in response to possible bioterrorism or other public health 

emergencies and its impact on military operations. 

Epidemiology & Clinical Features of SARS 

The causative agent behind SARS, a new coronavirus (SARS-CoV), 

was successfully identified only weeks after WHO’s global alert was 

announced.20 Human-to-human spread is the predominant mode of 
8 . . . The Impact of Quarantine on Military Operations

transmission of SARS, primarily involving the respiratory route via direct 

or indirect contact of mucous membranes (eyes, nose, or mouth) with 

infectious droplets.21 The virus has an insidious onset with an incubation 

period of 4 to 7 days, which occasionally may be as long as 14 days before 

the appearance of symptoms.

22 The non-specific clinical presentation of 

SARS makes it difficult to distinguish from routine upper respiratory 

infections. Although laboratory tests can be helpful in ultimately 

confirming a diagnosis, they do not reliably detect infection early in the 

illness. This is due to the fact that antibody, which is responsible for a 

positive test result, is detectable only after the first week of illness.23 The

viral load in an infected patient is initially low and reaches a peak during 

the second week of illness.24 This explains why no transmission has 

occurred from patients who have yet to develop symptoms and why most

cases of transmission have occurred with severe, hospitalized patients who

have a high viral load.25

This also explains why it was possible for an apparently healthy 

person to travel by air almost anywhere in the world after being exposed. 

The average number of secondary cases resulting from each case was 

estimated to be two to four, however, “super-spreading” occurred from a 

few infected person who were responsible for a disproportionate number 

of transmissions.26 For example, one patient in China was responsible for 

infecting 100 people on January 31, 2002, during a Chinese New Year 

celebration, 56 staff members during two subsequent hospitalizations, and 

19 family members.27 Although specific quarantine orders varied by 

country, large numbers of healthy people with an exposure history were 

placed in quarantine for up to 14 days given the known epidemiologic 

history of the disease and the limitations of laboratory testing. The length 

of quarantine was based on the estimated incubation period, which is

different for every disease, and the maximal incubation period for SARS 

was 14 days. This action was supported given that in the absence of a

vaccine, effective drugs or natural immunity, the only available public 

health strategies to limit the impact of SARS involved rapid identification 

of infected person and implementation of control measures to include 

isolation and quarantine.28
The Impact of Quarantine on Military Operations . . . 9

Quarantine & SARS 

Because little was known about the actual risk of transmission when 

the WHO issued its global health alert in March 2003, the actual methods 

used to implement quarantine against SARS varied by country. Options 

exist for setting up quarantine locations, and multiple strategies were

attempted during the outbreak. Quarantine of definitive contact cases such

as household or family members was the most intuitive and resulted in 

“home isolation” whereby contacts were urged to remain at home for a 10 

to 14-day period with telephone follow-up by public health workers in 

several countries.29 “Work quarantine” was commonly used for health 

care workers who had an exposure history without adequate protection 

allowing staff to continue working in the facility as long as they remained 

well.30 In situations where exposure history was less certain such as 

public locations where large numbers of people gathered, a variety of 

responses were attempted. At the extreme end of the spectrum, China 

used highly restrictive measures to include cordoning off of villages and 

restriction of travel, including the closure of public transit.31 Countries at

the other end of the spectrum used “snow days” as a quarantine strategy, 

which involved closure of schools, childcare centers, and other public 

buildings for a defined period of time.32

The use of quarantine for SARS also raised some difficult questions 

involving the law and protection of civil rights. Once again, isolation is 

more straightforward resulting in the confinement of ill individuals with a 

communicable disease. Quarantine is more complicated and the purpose 

is not to immediately stop all transmission of infection, since this would 

be unrealistic for most countries and nearly impossible given the severity 

of the measures that would be needed for such a goal.33 Even on a 

military installation with a higher degree of local control, this is a difficult 

challenge realizing the need to respect state laws or those of the host 

nation in an overseas environment. The purpose of quarantine is to reduce 

the incidence of new cases, resulting in an expectation that the number of 

infected individuals will peak, decline, and then reach zero if effective.34 

Ideally, quarantine rules of engagement are based on scientific information 

regarding the disease in question, which unfortunately was not initially 

possible with SARS. 

The Impact of Quarantine on Military Operations . . . 11

IV. SARS - International Lessons Learned 

Although it is generally accepted that isolation and quarantine

resulted in the ability to contain and control the SARS pandemic, the 

experience was different for every involved jurisdiction based on their 

underlying political environment, legal, and public health systems, health 

care infrastructure, law enforcement, and ancillary support capability. The

following review will discuss highlights from the SARS pandemic and key

lessons learned from China, Canada, Hong Kong, Singapore, Taiwan, and 

Vietnam.

China 

The SARS pandemic began quietly in China’s Guangdong Province 

in November 2002 when 305 individuals were diagnosed with “atypical 

pneumonia” resulting in five deaths.35 It is of scientific interest that the 

virus is believed to have originated in wild game animals sold in a 

Guangdong Province open market, and SARS-CoV “crossed the species

barrier” from animals to humans.36 These initial cases were not 

recognized as an emerging health threat and were not reported to local 

public health officials until January 21, 2003, or to the WHO until 

February 11, 2003.37 This delay in reporting combined with travel of 

infected individuals allowed “SARS to spread rapidly around the world, 

largely because persons infected with the SARS-associated coronavirus 

traveled on aircraft to distant cities.”

38 According to WHO, there were

reported cases of SARS in nearly every province and autonomous region 

in China by July 14, 2003.39 WHO publicly challenged China’s limited

reporting of SARS cases throughout Beijing in April 2003, which was an

unprecedented move by WHO.40 This action did result in greater

cooperation in the months to come. 

It is unclear how well prepared the public health system in China was

to manage a disease outbreak in 2002, however significant positive 

changes did occur the following spring. After April 2003, agencies within 

the Communist Chinese government “had declared war on SARS,” and

their Ministry of Health approved the listing of SARS as an infectious

disease on April 8, 2003.41 This was significant since there was no prior 
12 . . . The Impact of Quarantine on Military Operations

requirement to report anything dealing with SARS under the standing 

WHO treaty. The Chinese implemented strict isolation and quarantine 

programs with a 14-day requirement that were viewed by some as creating 

“virtual prisons” and resulted in questions from Chinese legal scholars 

about the legality of some measures taken by the Ministry of Health.42 

Provisions authorized the quarantining of entire villages with police 

empowered to enforce orders. A 10-year prison term was also approved 

for those who refused to comply with isolation or quarantine.43 It is

unclear how often law enforcement was actually needed to enforce 

compliance. 

By June 30, 173 persons were isolated and quarantined in 18 districts, 

four hospitals were isolated, seven residential communities, and seven 

construction sites were totally isolated. The isolation and quarantine 

program was a success, although questions remain regarding excessive 

tactics. China implemented a successful SARS case reporting system

linked with the CDC of China and the Ministry of Health which is still in 

effect, and the government allocated 11 billion yuan to establish a public

health emergency treatment system.44 It should also be noted that in 

Chinese, there is no word for quarantine; it is all “isolation.”45 However, 

the functional application was the same. 

Canada 

The first SARS cases appeared in Canada a week before WHO issued 

it global warning on March 12, 2003, allowing the disease to spread 

throughout Toronto for days secondary to inter-hospital transfers of 

patients who hadn’t been diagnosed.46 As one of the hardest hit countries 

by SARS, Canada followed only China, Hong Kong, and Taiwan in 

probable SARS cases. The index case was eventually traced to a 78-year 

old woman who returned home to Toronto on February 23, 2003, after 

visiting relatives in Hong Kong.47 There were 438 cases in two provinces, 

Ontario and British Columbia, before the SARS provincial emergency was

lifted on May 17.48 Unfortunately for Canada, a second phase of the 

SARS outbreak began on May 23 leading to concerns over decentralized 

control of the Canadian public health system with authority delegated to 

13 different provinces.49 SARS was subsequently added to the list of 

diseases under the federal public health authority on June 12, 2003.50
The Impact of Quarantine on Military Operations . . . 13

The government of Ontario was quick to initiate a quarantine and 

isolation strategy on March 25, 2003, ultimately resulting in the quarantine 

of 30,000 people in Toronto.51 As was noted in other countries, healthcare

workers were at high risk. In fact, health care workers accounted for over 

40% of all patients in Toronto. Four hospitals were designated as SARS 

facilities, and a “Code Orange” status was implemented resulting in the

suspension of non-essential services in all Ontario hospitals after the 

second outbreak.52 A large number of physicians were placed in 

quarantine as many public health facilities became increasingly 

conservative with application. This resulted in numerous articles in the 

press and literature written by physicians expressing concerns about the 

imposed quarantine process from a personal perspective.53, 54, 55, 56

The painful lesson learned was that “one patient’s unprotected 

transfer (son of the index case) would prove the worst “miss” of the early 

efforts to control the SARS outbreak.”57 If airborne infection precautions

had been taken to prevent transmission through respiratory droplets, the 

outcome would have been different. Home and workplace quarantine was 

successfully used in Toronto with high levels of compliance. Only 27 

cases required a written order mandating quarantine. High voluntary

cooperation was felt to be a direct result of actions taken by the federal 

and provincial governments to encourage compliance, such as providing 

special employment insurance coverage and expediting benefit payments. 

Although successful with quarantine, the decentralized public health

response with SARS left many feeling that “Canada is not adequately 

prepared to deal with a true pandemic.”58

Hong Kong 

The initial case of SARS in Hong Kong was traced to a physician 

who had been treating patients for atypical pneumonia in Guangzhou, 

China, and stayed in Hong Kong’s Metropole Hotel in March 2003.59 He

infected 7 people from the hotel and 100 hospital workers following his 

admission to Prince of Wales Hospital.60, 61 Another significant outbreak 

occurred in the Amoy Gardens apartment complex. One hundred thirty 

residents diagnosed with SARS and 241 placed in quarantine were linked 

to a visitor to the complex who had previously received treatment at 

Prince of Wales Hospital.

62 The government successfully implemented a 
14 . . . The Impact of Quarantine on Military Operations

10-day home quarantine program in addition to creating isolation camps 

outside the city of Hong Kong as an alternative for these residents.63 

Hong Kong International Airport is one of the busiest in the world and all 

passengers were required to complete health declarations in addition to 

having temperature screens complemented by the use of infrared devices 

to detect fever.64 Success of the public health initiatives in Hong Kong 

were attributed to a strong public education program, adequate central 

funding of programs, establishment of multi-disciplinary response teams, 

and the threat of force for quarantine non-compliance. Similar to the

experience in Toronto, support for quarantine efforts was enhanced by 

new laws that obligated employers to make reasonable efforts to protect 

the health and safety of employees and to ensure job security of those who 

complied with quarantine requirements.65

Singapore 

Singapore had their initial cases of SARS on March 14, 2003, 

following the admission of six patients to Tan Tock Seng Hospital with 

atypical pneumonia.66 Three index cases were identified as “superspreaders” and all had stayed at the Metropole Hotel in Hong Kong when 

the SARS-infected person was a guest.67, 68 Singapore received positive

global attention for their comprehensive and supportive approach to 

dealing with SARS, which was greatly facilitated by it existing public 

health structure and legal system.

69

On March 24, 2003, the Ministry of Health used its power under the 

Infectious Disease Act to initiate a 10-day home quarantine program for 

probable and suspected cases.70 A commercial firm was hired to serve

quarantine orders and install electronic cameras in homes of those in 

quarantine to ensure continuous contact and monitoring of twice daily

temperature checks.71 Quarantined persons could also choose to stay at

government facilities at a reasonable cost, and non-compliance with

quarantine orders was enforced by the threat of imprisonment. A unique 

outreach feature was a dedicated SARS television channel in addition to a 

Quarantine Order Allowance Scheme to help defray costs of home

quarantine.72

As in other countries, transmission in healthcare facilities was a major 

dilemma. In fact, 75% of their 238 cases were linked to hospitals and 
The Impact of Quarantine on Military Operations . . . 15

nursing homes, which triggered a 14-day home quarantine program for

those recovering from SARS after discharge.73 The four-pronged approach

implemented by the Ministry of Education (Contain, Safeguard, Screen, and 

Isolate) proved effective, and the most successful government actions

during the outbreak were the containment of hospital infections using a 

designated SARS hospital for all infected patients and prevention of

community infections as per the Director of Medical Services.74 WHO 

removed Singapore from its list of SARS-affected areas on May 31, 2003.75

Taiwan 

The first suspected case of SARS in Taiwan (Republic of China) was 

a businessman who traveled to the Guangdong province of China in 

February 2003 having returned through Hong Kong to be hospitalized two 

weeks later in Taiwan.76 Taiwan was in a unique predicament given that 

they had been excluded from WHO since 1972 when China refused to 

recognize their government, however, support was available during the 

SARS outbreak from the United States CDC.77 Initially, Taiwan refused

to conduct health screenings at immigration checkpoints and quarantine 

measures were limited. This changed dramatically after April 28, and two 

levels of quarantine were established, A and B. 

These levels were unique to Taiwan and were defined as follows: a 

stringent, mandatory 10-day quarantine was imposed on anyone arriving 

from a SARS-infected area (Level B quarantine) in addition to a

requirement for all arriving passengers to wear masks and complete

temperature checks.78, 79 People who had been in close contact with a 

SARS patient were quarantined for 10-14 days (Level A quarantine).80 By

the end of the epidemic, 131,132 persons had been placed in quarantine,

which included 50,319 close contacts of SARS patients and 80,813 

travelers from WHO-designated SARS-affected areas.81 Compliance was

good with only 286 (0.2%) violators of quarantine, and probable SARS 

was diagnosed in 112 (0.2%) people in Level A, but only 21 (0.03%) 

people were diagnosed in Level B.82

Once again, healthcare workers were at highest risk of becoming 

infected with SARS, and two hospitals were placed in a 14-day quarantine

which resulted in significant negative publicity based on poor planning 

and support for those in quarantine.83 Enforcement of Taiwan’s SARS
16 . . . The Impact of Quarantine on Military Operations

regulations took a political toll based on allegations of slow response 

resulting in the resignation of both the Minister of Health and the Director 

of Taiwan’s CDC.84 Once initiated, concerns arose regarding an excessive

response based on Taiwan’s two levels of quarantine. A report completed 

by the United States CDC questioned Taiwan’s quarantine implementation 

strategy and stated, “more study is needed to determine whether the 

logistics and cost of quarantine warrants its use.”

85 These concerns were 

specific to the country of Taiwan. 

Vietnam 

The Vietnam French Hospital of Hanoi reported a case of an “unusual 

influenza-like virus” to the WHO on February 28 in a Chinese-American 

businessman who had come from southern China.86 Dr. Carlos Urbani, a 

WHO infectious disease specialist, responded and promptly alerted the

Vietnamese government of the disease and eventually coined the term 

“Severe Acute Respiratory Syndrome.”87 Unfortunately, Dr. Urbani 

would die from the previously unknown pathogen in a matter of weeks. 

The SARS epidemic in Vietnam was primarily hospital-based and all 

cases were traced to the initial index case. Of the first 60 patients with 

SARS, more than half were health care workers, all deaths involved

doctors and nurses, and most of the staff made the decision to quarantine

themselves to protect their families and community.88

Vietnam was the first country to contain the spread of SARS and be

declared SARS-free by WHO. Positive outcomes were attributed to

Vietnam’s decision to deal with the outbreak openly and decisively, 

although with limited resources compared to other SARS-infected 

countries.89 Stringent restrictions on entry or travel across the border into 

China proved critical, and Vietnam maintained control of border entry 

points with temperature screenings and infrared thermal imagers even 

after WHO declared them SARS-free.90 Travel in or out of the country 

was not allowed if fever was present, and quarantine was mandated for 

these travelers.91 Throughout the SARS outbreak, the Vietnamese central 

government presented an image of continued cooperation between all key 

departments and maintained close cooperation with WHO. To minimize 

the burden of SARS and encourage medical treatment, the government 

announced that SARS treatment would be free of charge for citizens and 
The Impact of Quarantine on Military Operations . . . 17

foreigners alike.92 Although a Communist country with limited resources, 

Vietnam’s success with implementing a strategy of early detection, 

isolation, and quarantine was most impressive to the industrialized world. 

Summary 

Several key points for military commanders should be highlighted

from the international lessons learned regarding quarantine and SARS. 

First and foremost is the understanding that the most severe biologic event 

a commander may encounter is a previously unknown disease with 

human-to-human transmission, primarily involving the respiratory route. 

Although agents like smallpox would also have serious implications, 

response plans have already been developed and treatment options exist. 

A new disease like SARS or a genetically-altered agent that may be used

by a bioterrorist requires additional planning for this worst-case scenario.

Quarantine needs to be part of the strategy as was shown with SARS. 

Second, delay in implementing quarantine can have devastating 

effects that result in loss of situational control as occurred in China. 

Decisive actions must be taken and coordinated up the chain of command 

prior to a commander having all the answers. This includes notification of 

key organizations such as the CDC or WHO. Third, healthcare workers 

are at highest risk of becoming exposed or infected prior to identification 

of the outbreak, which may result in the need for quarantine of entire 

medical facilities. 

Fourth, cooperation between support agencies is critical to educate 

the community, encourage medical identification and treatment, increase 

patient compliance, enforce requirements when needed, and obtain overall 

buy-in from the public. This begins with leadership and can be spread 

throughout the organization following comprehensive planning to ensure a

coordinated response. Fifth, broad legal and policy challenges exist in 

responding to an infectious disease outbreak, and guidance is needed to 

orchestrate a prompt and effective response. This should be addressed 

prior to a crisis. 

Sixth, the quarantine implementation plan chosen by leadership 

should provide the best opportunity to contain the disease without 

enforcing excessive or unrealistic restrictions on a community as occurred 

in China and Taiwan. Finally, each disease is unique requiring an 
18 . . . The Impact of Quarantine on Military Operations

understanding of its epidemiology to ultimately develop a definitive 

treatment strategy, however the initial response prior to identification of 

the infectious agent should be non-specific and cover a worst-case 

scenario. This lesson was emphasized by the Canadian experience with 

SARS. 
The Impact of Quarantine on Military Operations . . . 19

V. Quarantine Laws 

The challenge of protecting the public’s health without unnecessarily 

infringing on personal rights and freedoms begins with an understanding 

of federal and state laws regarding restriction of movement. States have 

the primary responsibility for protecting the public health of citizens per 

the 10th Amendment of the U.S. Constitution.93

Significant variability exists between states regarding local laws and

regulations for quarantine, which has created some confusion with the

potential for fifty different rules of engagement. Each state’s inherent 

“police power” provides the opportunity for quarantine to be enforced to 

safeguard the health, safety, and welfare of its citizens. The governor may 

call upon the state’s National Guard to support implementation of a

quarantine. 

The federal military could also support civilian law enforcement as 

authorized by the Stafford Act following a request for DoD resources by

the state governor. The military is not authorized to enforce quarantine 

outside of a U.S.-based military installation as regulated by the Posse

Comitatus Act and DoD Directive 5525.5, DoD Cooperation with Civilian 

Law Enforcement Officials.

94 An enforcement role is possible as an

exception to Posse Comitatus, but requires authorization by the President 

using Insurrection Act powers or Constitutional Authorities.95

If quarantine was required on a military installation in the United 

States, the installation commander would be responsible for ongoing 

military operations and enforcement of quarantine. In the event of a

biological attack on a military installation in the United States, parallel 

lines of command would exist as per Air Force Doctrine Document 2-1.8, 

Counter NBC Operations, with the installation commander in charge of 

military operations and the Federal Bureau of Investigation (FBI) having 

control of the crime scene.96 The CDC would also play a prominent role 

to prevent the transmission and spread of a communicable disease within 

the U.S. as covered in U.S. Code Title 42 and Executive Order 12452.97
20 . . . The Impact of Quarantine on Military Operations

Model State Emergency Health Powers Act 

When the anthrax letters surfaced in October 2001, state quarantine 

laws were exposed as being antiquated with many unchanged from their 

original versions and most pre-dating the 1960’s Civil Rights Act.98 In

response to a request from the Bush administration, James Hodge from 

Johns Hopkins University and Lawrence Gostin from Georgetown 

University’s Center for Law and the Public’s Health drafted model

legislation, the Model State Emergency Health Powers Act (MSEHPA), to 

protect the public’s health in an era of bioterrorism.

99 The MSEHPA 

facilitated the detection, management, and containment of public health 

emergencies at the state level while safeguarding personal and proprietary 

interests.100

This document covered bioterrorism in addition to natural epidemics 

and was derived from existing federal and state laws, lessons learned from 

recent exercises such as TOPOFF and Dark Winter, and a meeting of 

experts in public health, emergency management and national security in 

April 2001.101 Article VI, sections 604 and 605, stipulated legal and 

procedural considerations during isolation and quarantine. The MSEHPA 

“permits public health authorities to physically examine or test individuals 

as necessary to diagnose or treat illness, vaccinate or treat individuals to 

prevent or ameliorate an infectious disease, and isolate or quarantine an

individual to prevent or limit the transmission of a contagious disease.”102 

It was recommended for states to make changes to their existing health 

codes using this modern statutory framework of public health powers to 

better prepare for public health emergencies. 

The MSEHPA has received criticism over the perceived loss of civil 

liberties resulting from many of the provisions of the act. In regards to 

quarantine, the authority of public health officials to enforce a quarantine

has been criticized as being based on an inappropriate concern that neither 

physicians nor citizens are likely to cooperate with public health officials

in the event of a bioterrorism attack.

103 The TOPOFF and Dark Winter 

exercises used to develop the MSEHPA were also felt to be unreasonable 

given the high level of voluntary cooperation on the part of the public after 

the September 11, 2001, terrorist attacks and anthrax letters.104 If a

quarantine law is needed, it was suggested that it should be a federal law, 

not a state law since bioterrorism is a matter of national security.105 
The Impact of Quarantine on Military Operations . . . 21

Critics complained that MSEHPA was a dangerous proposal that 

sacrificed civil liberties for an effective public health response to a 

bioterrorist attack. 

In actuality, the MSEHPA subsequently obtained wide support in the

U.S. because it was drafted as an improvement over many existing state 

laws that did not provide standards or procedures for the exercise of power 

in response to a public health emergency. The lessons learned from the 

recent SARS epidemic also bring into question the concerns raised 

regarding cooperation, further supporting the MSEPHA. The Act has 

been introduced in whole or part through bills or resolutions in forty-four 

states, the District of Columbia, and the Northern Mariannas Islands.106 

Thirty-three states have passed bills or resolutions that include provisions 

from or closely related to the Act.107 Unfortunately, significant variability 

still exists between states regarding the Act’s provisions and commanders 

need to have a good understanding of the local rules of engagement before 

supporting quarantine operations outside of a military installation. 

The Impact of Quarantine on Military Operations . . . 23

VI. Quarantine Policy 

The epidemic is seldom mentioned and most Americans 

have apparently forgotten it. This is not surprising. The 

human mind always tries to expunge the intolerable from

memory. 

–H.L. Mencken108

The critic and author H.L Mencken wrote the above statement in 

1956 as a survivor of the 1918 “Spanish influenza” pandemic, which took 

the lives of 675,000 Americans and 25 million worldwide in a few tragic 

months. The Spanish influenza pandemic claimed more lives than did 

fighting in World War I, and valuable lessons from public health officials

who waffled with quarantine decisions and initially denied the danger 

have been almost forgotten.109 The 1918 influenza pandemic was the last 

time that the United States (U.S.) instituted a large-scale quarantine, and 

Department of Defense (DoD) leadership has little familiarity with 

quarantine procedures, requirements, and implications.110 Although no 

document is specific only to quarantine, guidance has recently been 

created to address restriction of movement in response to a disease 

outbreak. 

DoD/Federal Policy 

Present policy on quarantine implementation in DoD was drafted 

following the SARS outbreak of 2003 and is contained in DoDD 6200.3, 

Emergency Health Powers on Military Installations. The release of this 

document on May 12, 2003, recognized the essential need “to protect 

installations, facilities, and personnel in the event of a public health

emergency due to biological warfare, or terrorism, or other public health 

emergency communicable disease epidemic.”111 DoDD 6200.3 empowers 

commanders to declare public health emergencies and impose quarantine 

on installations under their command. It also requires that every military 

commander designate a Public Health Emergency Officer (PHEO), who 

shall be a senior health professions military officer or DoD civilian 

equivalent, and the PHEO will identify, investigate, and control disease 
24 . . . The Impact of Quarantine on Military Operations

outbreaks.112 In regards to quarantine, the PHEO plays a key role as a

consultant to the installation commander providing medical 

recommendations that may result in special powers being exercised to

prevent the spread of communicable disease. DoDD 6200.3 also 

authorizes the Director of the CDC “to establish a quarantine to prevent 

the spread of communicable diseases into the United States, from State to 

State, or, in time of war, affecting military and other national defense 

personnel, and to support State quarantines.”113

Additional disease specific guidance regarding quarantine and 

isolation can be found in Annex C of the DoD Smallpox Response Plan 

and the recently issued memorandum titled DoD Guidance for Pandemic 

Influenza Planning and Response. The CDC also provides disease 

specific quarantine guidance for SARS in the SARS Response Plan, 

Supplement D: Community Containment Measures, Including NonHospital Isolation and Quarantine and smallpox in the Smallpox Response 

Plan and Guidelines, Guide C: Infection Control Measures for Healthcare

and Community Settings and Quarantine Guidelines. Although the latter

two documents were prepared for civilian public health officials, the 

information is equally pertinent to military officials. 

USAF Policy 

A review of Air Force Doctrine revealed minimal additional guidance 

on establishing quarantine in response to a biological attack.114 AFI 10-

2501, Full Spectrum Threat Response (FSTR) Planning and Operations, 

briefly mentions quarantine and AFI 48-105, Surveillance, Prevention, 

and Control of Diseases and Conditions of Public Health or Military

Significance, is being updated to include guidance from DoDD 6200.3.115 

A new AFI 10-2603, Commanders’ Guide to Emergency Health Powers 

on Military Installations, is being drafted and will implement key 

provisions contained in DoDD 6200.3. Overall, guidance for installation 

commanders involving operational implications for implementing 

restriction of movement measures is still limited. 
The Impact of Quarantine on Military Operations . . . 25

VII. Lessons Learned from Bioterrorism Exercises 

Multiple bioterrorism exercises have been conducted in the U.S. both

prior to and following September 11, 2001, and many have provided 

helpful input regarding future use of quarantine in response to a public 

health emergency. A recurrent theme in all exercises was that a biological 

attack is a unique form of terrorism given its inherent insidious onset 

where the first evidence of attack may not be appreciated until days later

once patients present to medical facilities with non-specific symptoms. 

Time lost in sorting out that an attack or disease outbreak has even 

occurred and in implementing a restriction of movement when appropriate 

places increased emphasis on the need for planning and exercising such 

events. Sound planning, guidance, exercising, and leadership are the 

critical factors. 

TOPOFF 

Operation TOPOFF (Top Officials) has been conducted twice, and 

the first exercise was particularly instructive regarding use of quarantine.

The original TOPOFF occurred in May 2000 and involved a pneumonic 

plague outbreak in Denver, Colorado. Of note, Colorado’s bioterrorism 

and pandemic influenza response law was not enacted to prepare for the 

exercise, but proved extremely useful and led to the recommendation that 

other state health agencies review their statutory authority to adequately

prepare for a similar event.116

In this exercise, a Yersinia pestis aerosol had been covertly released 

three days earlier at the city’s center for performing arts and led to 3,700 

cases of plague with 950 deaths and 780 secondary cases by day three of 

the exercise.117 Isolation became impossible during this exercise due to

overwhelming numbers presenting to local hospitals, ultimately resulting 

in an executive order by the governor quarantining all persons in

metropolitan Denver in their homes. However, it quickly became clear 

that quarantining two million people is not an easy task and was unlikely 

to be successful given limitations involving enforcement and the logistics 

of carrying out this monumental task without additional manpower. The 

key lesson learned was that equal effort must be given to controlling the
26 . . . The Impact of Quarantine on Military Operations

spread of disease compared to the treatment of ill persons or the demand 

for health-care services will not diminish.118 This exercise also brought

problematic issues of leadership and decision-making to the forefront with 

delays resulting in the inability to contain a highly contagious disease 

outbreak in a large urban community. This is highlighted in the following

comment from one observer: “Containing the epidemic did not receive

high enough priority. No amount of incoming federal resources could stop 

the epidemic without a priority on containment.”119

Dark Winter 

Dark Winter was an exercise that occurred in June 2001, involved 12 

high-level government and military participants who portrayed members 

of the National Security Council, and simulated a covert smallpox attack 

on the United States.120 The tabletop exercise involved three simultaneous

attacks infecting 3,000 people in separate shopping malls in Oklahoma

City, Philadelphia, and Atlanta. In regards to quarantine, it was

recommended, but the potential implications were clearly not understood 

and tension developed between state and federal authorities regarding 

decision control over disease containment measures.121 The inability to

enforce travel restrictions was ultimately appreciated. This led to the 

understanding that leaders must gain the trust and sustained cooperation of 

the American people if spread of the contagious disease was going to be

controlled. The projected outcome of this exercise was 3 million cases of

smallpox and approximately 1 million deaths.122

Sooner Spring 

A third exercise of note involving quarantine was Oklahoma’s Sooner 

Spring bioterrorism exercise, which occurred in April 2002. This involved 

four operational exercises in different cities throughout the state to include 

smallpox in Tulsa and Oklahoma City, pneumonic plague in McAlester, 

and botulism in Lawton.123 Similar lessons were observed to include

limitations involving quarantine enforcement and sustainment in addition 

to the need for thorough quarantine implementation planning to 

realistically impose restrictions of movement.124 Participants discussed 
The Impact of Quarantine on Military Operations . . . 27

the option of varying gradations of quarantine ranging from voluntary 

travel restrictions to in-hospital enforced isolation as a possible solution to

balance limited resources with a desire to maintain a more “normal” life

for residents within the cordon.125 Another critical issue was the decision

to declare quarantine prior to CDC confirmation of disease, which will be

an issue for military commanders who may not have immediate access to 

such resources, especially if stationed outside the continental United 

States. 

USAF Exercises 

Research efforts are also ongoing within the Air Force with training 

and exercise programs that involve restriction of movement in response to 

a bioterrorism event. The operational impacts of implementing quarantine

were initially tested during exercises at Ramstein Air Base, Germany, in 

July 2003.126 These exercises involved anthrax and smallpox scenarios, 

and provided preliminary insights into how biological attacks might affect 

operations. Additional operational research is ongoing at Kunsan Air 

Base, Republic of Korea (ROK).127 Results from these efforts are 

forthcoming. 

The Impact of Quarantine on Military Operations . . . 29

VIII. Military Operations and Quarantine 

Although all installation commanders will have the same desire to

maintain full operational capability in the event of a public health 

emergency requiring quarantine, the challenges will be different based on

whether the installation is located within or outside the continental United

States. In general, legal guidance will be more straightforward with 

quicker access to key ancillary support agencies such as the CDC for those 

stationed within the continental United States. It will be critical to have a 

thorough understanding of state laws and to exercise local emergency 

response plans since any event on a military installation will have

implications for the local community given the presence of a civilian 

workforce and the fact that a biologic agent is not limited by the fence 

surrounding an installation. Unfortunately, legal issues involving 

implementation of quarantine outside the continental U.S. becomes 

significantly more complicated. 

At overseas installations, U.S. military personnel and civilian

employees of the DoD are covered by international agreements known as 

Status of Forces Agreements (SOFAs) between the U.S. Government and 

allied nations.128 DoDD 6200.3 states that implementation of restriction of 

movement at overseas U.S. installations is dependent on “local conditions, 

and requirements of treaties and agreements, and other arrangements with 

foreign governments and allied forces.” The Headquarters Air Force

Judge Advocate (AF/JA) conducted an informal review of DoDD 6200.3

and concluded that the AF would need the consent and cooperation of the

host-nation to implement the directive.129 Multiple concerns have been

raised regarding implementation of a quarantine to include coordination 

with local officials to declare a public health emergency, access to 

facilities used by host nation forces and their civilian components, 

gathering and sharing of information that impacts privacy laws, and 

coordination with local security forces to enforce quarantine and secure 

the installation.130 These are just some of the critical issues which require 

the establishment of local agreements between the installation and the 

local authorities in order to implement a quarantine in the event of a public

health emergency. 
30 . . . The Impact of Quarantine on Military Operations

DoDD 6200.3 states that commanders have “special authority” during 

a declared public health emergency to initiate restriction of movement 

measures over military and non-military persons present on an installation. 

This is important based on two recent cases, which revealed the limitations

of a commander’s authority to enforce restriction of movement prior to 

DoDD 6200.3. The first occurred with U.S. Forces Korea in Seoul 

following the September 11, 2001, attacks and involved the inability of the

commander to compel civilians and contractors to remain on base in 

compliance with an imposed curfew during certain hours without 

receiving overtime pay for those hours.131

The second case involved DoD teachers. They could not be 

prevented from traveling to China during the SARS outbreak to prevent 

exposure to the highly contagious disease based on labor laws that 

prevented such actions.

132 The present requirement for a commander to 

exercise “special powers” is to declare a public health emergency and

report this action up the chain of command to the Secretary of Defense.133 

The concern with this requirement is the delay that may occur in activating 

a quarantine based on the indecision of whether an outbreak has truly 

occurred, which is all the more challenging at an overseas installation 

where confirmatory laboratory analysis of patient samples may take days

in the best possible scenario. The SARS experience highlights this valid 

concern as the lesson learned with this previously unknown disease was 

that delay in instituting restriction of movement and quarantine can have 

devastating effects that are exponential when dealing with most 

contagious diseases with worldwide implications.
The Impact of Quarantine on Military Operations . . . 31

IX. Recommendations for Commanders 

In the fight against bioterrorism, a commander must understand that 

he is facing two enemies, the terrorist and the biologic agent. The latter,

which can only be seen at the microscopic level, is the more lethal

opponent with the added advantage of insidious, widespread infiltration 

before an attack is even identified. Although sensors are being used to 

help with early detection, the most likely way a commander will first be 

aware of an outbreak on the installation is when patients arrive at the local

medical facility for help. This leads to the initial challenge facing

commanders, determining when to announce a public health emergency 

and whether quarantine is indicated. The recommendation is to initiate a

“preemptive” action based on the perceived level of risk. 

#1. Initiate preemptive quarantine at the first indication of a

possible biologic attack to maximize the probability of disease 

containment. 

Multiple scenarios are possible for a biologic weapons attack given

the option of an overt versus a covert attack using one or multiple agents. 

In addition, the advent of genetic engineering has increased the likelihood 

of a terrorist using a biologic agent that has been altered to be resistant to 

known treatment or vaccination.134 A public health emergency may also 

be secondary to a natural disease outbreak of a known or new disease as

occurred with SARS, but once again, this will frequently be unclear during 

the initial 72 hours after declaration of an emergency. With limited 

laboratory options for an overseas facility, it will take greater than 72

hours before confirmatory laboratory information is available, and a 

commander cannot afford to wait on definitive results before making a

decision. 

This initial recommendation is based on three key issues regarding 

quarantine. First, indecision can result in loss of containment, as was the

case in many of the bioterrorism exercises completed in the U.S. and in 

the real-world experience with SARS. Second, with Air Force’s mastery 

of “rapid global mobility” comes the potential for global spread as was

clearly demonstrated with SARS. Finally, public fear of the unknown that 

can occur with restriction of movement can be as dangerous as the disease 

in question. Therefore a set strategy of preemptive quarantine that has 
32 . . . The Impact of Quarantine on Military Operations

been exercised and accepted by a military community can limit the 

potential for panic and enhance cooperation. 

This strategy also requires clarification of the commander’s authority 

in declaring quarantine for an overseas installation, which will be different 

for each country as per the SOFAs. Although less confusing in CONUS, 

there are still issues to be clarified with state emergency response teams 

that must be exercised prior to the actual declaration of a public health 

emergency. The proposed plan would be to prepare for the worst-case 

scenario of a highly contagious biologic agent with airborne spread, and 

then back off restrictions after the initial 72 hours once more information 

is available about the disease in question. 

Such a strategy would be appropriate for diseases such as plague,

smallpox, viral hemorrhagic fevers like Ebola, and SARS, but once again, 

this recommendation is based on the likely scenario of not having a 

definitive diagnosis during the initial 72 hours. This is similar to a 

football team which has designed and practiced the first several offensive 

series, and has the opportunity to alter the game plan at half time once 

more information is available about the opponent. Although it is true that

mandatory quarantine should not be enacted by a commander without

legal consultation and appropriate planning to include security

capabilities, public affairs plans, and basic supply issues, this process

should be completed and exercised at every military installation in 

preparation for an attack. The multidisciplinary response required for a

successful quarantine strategy leads to the second recommendation. 

#2. Ensure total military community support and involvement 

with quarantine planning and response. 

Although key players involve those designated in DoDD 6200.3 to 

include the PHEO and other critical medical personnel, effective 

implementation of quarantine requires much more than a coordinated 

medical response. As demonstrated in multiple exercises and the SARS 

pandemic, one of the greatest challenges involves enforcement of 

quarantine regulations, which primarily falls upon security forces 

personnel in the overseas setting. As previously noted, standing policy to 

secure installations, maintain quarantine areas, and enforce restricted

movement of civilians who work on the facility requires clarification with 

local officials. Pubic affairs and the communications squadron will also 
The Impact of Quarantine on Military Operations . . . 33

play key roles in disseminating approved information to the community, 

which needs to be ongoing and readily available throughout the quarantine 

period. Timely release of information from leadership and easy access to 

personnel with answers to questions from the “worried well” were keys to 

success during the SARS pandemic. Services staff will be critical to 

ensure that lodging and food are available to those affected by restricted 

movement, with emphasis given to dependents in home-based quarantine. 

Mortuary affairs will play an important role in management of the

deceased with the added burden of disease containment given the 

infectious potential of human remains. Legal will have a prominent 

position not only in providing advice to the commander to ensure SOFAs 

with host nations are being met with implementation of restriction of

movement policies, but in responding to individuals who contest the 

reason for their quarantine. Operations will be needed to handle air traffic 

while focusing on disease containment as additional manpower and 

supplies are brought to the installation and select individuals will 

ultimately be allowed to leave as will be discussed below. The entire

installation will be stressed in a quarantine setting for this initial 72-hour 

period, and continued sustainment will only be possible with additional 

support and supplies. 

#3. Establish an alternate medical facility for the triage and 

treatment of all patients based on the expected contamination of the 

primary facility. 

Emphasis on early identification of a biologic attack frequently falls

upon junior medical personnel who are challenged with potentially 

diagnosing and responding to conditions they have only read about in 

textbooks. That being said, the impact one astute provider can make 

should be highlighted in training as early recognition will save lives. 

Consultants in infectious disease and access to national laboratories will 

not be readily available at overseas facilities, thus placing increased 

pressure on providers challenged with making a timely diagnosis with 

limited or possibly conflicting information. Given this setting, it is 

reasonable to expect that the medical facility will need to be quarantined 

because a majority of staff may have already been exposed to the biologic 

agent once recognized, as was the case with SARS. In fact, exercises have

shown that patients with initial symptoms similar to a routine upper 
34 . . . The Impact of Quarantine on Military Operations

respiratory infection or the “flu” may present for care 2 to 3 days before 

the outbreak is identified, but significant spread has already occurred at 

this point. The PHEO will play a key role in helping the commander

decide which staff have been potentially exposed based on work history 

and need to remain in the primary medical facility compared to those who 

can safely work in the alternate facility. Presenting symptoms will 

obviously vary based on the disease in question. The medical facility, 

regardless of the size, should be used to support those patients who have 

been diagnosed and require isolation. Respiratory spread precautions to 

prevent transmission through airborne droplets should be the standard 

until further information is available. This will require use of facemasks, 

respirators, and airborne infection control isolation rooms, in addition to 

gloves, gowns, and good hand washing. 

By moving select staff who do not require quarantine to an alternate 

facility, resources can now be used to safely support the installation with 

the expectation that a significant number of “worried well” patients will be

presenting for care in addition to those with disease. Staffing and supply

limitations will be the primary challenge in the alternative facility until 

additional resources become available. All patients should be triaged into 

one of three categories for simplicity. First, those suspected of having 

active disease needing isolation, which needs to occur away from the

alternate facility and may be best accomplished at the medical facility. 

Second, those at high risk who may have been exposed and require 

quarantine. This group will include the “worried well” if they meet preestablished criteria. Third, will be all others. Clarifying what criteria will 

be used to justify need for quarantine should be quickly established with 

the help of the PHEO, and this strategy will be unique to the disease 

process that is occurring. A facility that might be considered for patients 

requiring quarantine could be billeting given the need for ongoing care 

and feeding in a centralized location. Routine patients from the third 

group should be appropriately treated at the alternate facility with the goal 

of limiting exposure from patients requiring isolation or quarantine. 

Maximal emphasis should be given to preventing contamination of staff in

the alternate facility by strict enforcement of infection control precautions.

Additional challenges for medical personnel will include 

transportation of acutely ill patients who require isolation from wherever

they are diagnosed using dedicated vehicles and staff to limit spread of 
The Impact of Quarantine on Military Operations . . . 35

disease. Visits may also need to be arranged for those patients in homebased quarantine settings to monitor status and provide ongoing 

assessment for a change in status. Life skills staff will be challenged to 

provide mental health support to the masses, realizing that the “worried 

well” in addition to those stressed by quarantine and isolation will need 

continuous support. Finally, public health personnel will be tasked with 

the burden of investigating cases for sources of infection and help define 

the distribution of illness. Given that a majority of medical staff may

require quarantine themselves based on exposure to index cases who 

presented prior to declaration of the public heath emergency, one of the 

immediate needs will be additional medical staff and supplies to include 

face masks and respirators to maintain respiratory isolation precautions. 

The goal will be to provide support for the initial 72 hours until additional 

resources arrive. 

#4. Consider a full spectrum of options during quarantine 

planning. 

There is a misunderstanding that only one type of quarantine exists, 

that being compulsory. Although this may be appropriate for mission 

essential personnel in operations and medical positions, other options exist 

for the rest of the community. Mandatory “work quarantine” will be

needed for mission essential personnel who ideally should not leave their 

buildings for the initial 72 hours. This will result in logistical concerns 

regarding care and feeding issues, and this needs to be planned for in 

advance. As occurred during SARS, implementation of quarantine was 

flexible in regards to the public with voluntary home-based and work 

quarantine. Passive and active monitoring of people in a voluntary 

quarantine setting will need to be arranged with support from medical staff 

to ensure ongoing support using minimal manpower requirements. Other 

options include “snow days” which involves closure of schools, day care

facilities, and other public gathering places and implementation of curfew

to restrict movement of vehicles except in emergency settings. The 

commander will need to seek legal counsel to clarify options to restrict 

movement of civilian personnel going off base, but a closed facility will

be necessary for the initial 72-hour period and contingency lodging should 

be planned. Another key lesson from SARS was that 100% quarantine 

was not needed for success, but this should not limit the degree of 
36 . . . The Impact of Quarantine on Military Operations

planning for this strategy. Installation support for this initiative will be

directly related to the effort given to planning and community education. 

#5. Contain spread of biologic agents when moving people and 

protect aircraft for long-term use.

Another challenge in dealing with a bioterrorist attack at an overseas

installation will involve continuing the flow of forces in and out of country

via airlift while maintaining disease containment and protecting aircraft 

for long-term use. A plan proposed by Bruce Bennett of RAND involves 

a “transload concept” whereby potentially contaminated aircraft leaving

the overseas facility fly to a pre-established transload base where

passengers and cargo are temporarily quarantined until cleared for travel 

back to the U.S. in a clean aircraft.135 Disease containment is the goal.

Those patients in isolation with confirmed disease should not be moved 

from the overseas installation, and those in quarantine should also not be 

moved initially until cleared from quarantine. This will not be an issue 

during the initial 72 hours as the entire installation will be in quarantine 

for this period. Remains of the deceased should not leave the country 

during the initial 72 hours, and legal involvement may be needed to clarify 

future options to include keeping remains in country, cremation, or 

transport via sealed containers. People ultimately cleared for travel should 

go through a staged quarantine at the transload base prior to return to a 

repatriation location in the U.S. for an additional quarantine period.136 

Maximal efforts should be made to prevent the spread of disease at 

airfields, and aircrew should be closely monitored for symptoms that

would require quarantine. Overall, airfields will require the highest degree 

of restricted access to limit movement of people and supplies until they 

have been decontaminated and cleared for travel. Decontamination 

standards will need to be established for aircraft leaving the potentially 

exposed airfield. The standards will be different from those required for

chemical agents, since decontamination may not be necessary or effective 

for a specific biologic agent following identification. The emphasis 

during the initial 72-hour period will involve inbound manpower and

supplies to support the quarantine operation. 

#6. Relax quarantine restrictions after the initial 72 hours once a 

diagnosis is confirmed and disease-specific measures can be 

implemented. 
The Impact of Quarantine on Military Operations . . . 37

It is assumed that additional support will be available after a 72-hour 

period, which will hopefully result in confirmation of a diagnosis.

Significant information is available through the CDC for quarantine and 

treatment options based on a specific biologic agent, but this will be of 

little use until the disease is identified. The decision of when to stop a 

quarantine is of equal importance to initiation, but this will generally be a 

decision made in a more controlled setting with maximal resources and 

information. It is possible with a new disease that quarantine 

recommendations may be unclear for some time as was initially the case

with SARS, however, the final decision of when to relax quarantine 

restrictions should cover a worst-case scenario. This will occur after the 

initial 72-hour period. 

In summary, these recommendations are made focusing on quarantine 

implementation to contain a disease in the overseas environment, and how 

a commander can carry out effective operations while adhering to 

quarantine requirements during the initial 72-hour period following 

exposure to a biological agent. 

The Impact of Quarantine on Military Operations . . . 39

X. Conclusion 

Quarantine is an effective public health measure that may be the best 

and last option for disease containment, especially when the diagnosis has 

not been established or no treatment plan exists for a given disease. The 

decision process for an installation commander must be different than in a 

civilian setting if the goal is to maintain operational capability. The focus 

must be on the initial 72 hours since the ramifications of a delay in action 

could be devastating to successful mission accomplishment and may result 

in unintentional global spread of disease. Given the inherent “fog of war,” 

it may not be clear whether an outbreak has occurred, however, early use 

of quarantine implementing the full spectrum of options gives a 

commander the best opportunity for disease containment while 

maintaining operational capability. 

This strategy is not dependent on the source or type of biologic agent 

encountered, but should be equally effective for a terrorist attack or a 

natural disease outbreak. This approach is based on the logic that it is 

better to establish a few days of potentially unnecessary quarantine based 

on a worst-case scenario and subsequently be proven wrong, than to delay 

and allow the spread of a deadly disease through inaction. A policy of 

“preemptive quarantine” whereby maximal restrictions are initially

implemented and are gradually scaled back as the fog lifts and more

information is known about the potential outbreak will provide the best

opportunity for mission success. This will only be effective if policies are 

in place and exercised prior to an event, and the community is well 

educated on the process to minimize fear and encourage compliance 

through faith in leadership. Restrictions of movement can be quickly 

modified and ideally limited or discontinued once more information is 

available and the disease is identified, however, this process takes time.

Once again, this approach would be unique to a military installation and 

would be most applicable for a facility outside of the continental United

States, which does not have the benefit of the many resources now 

available through the Department of Homeland Security and state 

emergency planning initiatives. 

The dangers of a bioterrorism have become a realistic concern for 

most Americans following the attacks of September 11, 2001. Federal, 
40 . . . The Impact of Quarantine on Military Operations

state, and DoD authorities have appropriately developed and updated 

policies and regulations to implement life-saving measures such as 

quarantine in the event of a public health emergency, however, work 

remains to be completed. Although civil liberties may be impacted with 

quarantine, these actions are justified given the potential ramifications of a

deadly biologic agent attack. Surveillance, infection control, isolation, 

and most importantly, quarantine to contain and control a disease outbreak 

will be the key to success, and the Air Force has much to learn involving 

the successful implementation of quarantine given the broad impact of this 

strategy. We must never forget the harsh lessons from past epidemics, no 

matter how painful the memories may be. Further study is indicated to 

clarify the impact of quarantine on military operations and help guide the

development of future policy. 
The Impact of Quarantine on Military Operations . . . 41

Notes 

1. Wolfgang Petersen, Outbreak, Hollywood, CA: Warner Brothers, 1995. 

2. Ibid. 

3. United States Air Force Counter-Chemical, Biological, Radiological, Nuclear, and

High-yield Explosive (C-CBRNE) Master Plan, Headquarters, USAF, 30 June 2004, 14. 

4. “History of Quarantine,” CDC – Division of Global Migration and Quarantine,

On-line, Internet, 14 September 2004, available from http://www.cdc.gov/ncidod/dq/

history.htm.

5. Ibid. 

6. Mike Mitka, “SARS thrusts quarantine into the limelight,” JAMA, 290, no. 13 (1

October 2003): 1697. 

7. Ibid. 

8. Ibid. 

9. “Facts about Isolation and Quarantine,” CDC – Division of Global Migration and

Quarantine, On-line, Internet, 14 September 2004, available from http://www.cdc.gov/

ncidod/dq. 

10. Executive Order 12452, “Revised List of Quarantinable Communicable 

Diseases,” 22 December 1983. 

11. Ibid. 

12. “History of Quarantine,” CDC – Division of Global Migration and Quarantine. 

13. Ibid. 

14. CDC Public Health Guidance for Community-Level Preparedness and Response

to SARS Version 2, Supplement D: Community Containment Measures, Including NonHospital Isolation and Quarantine, 8 January 2004, 4.

15. Quoted in Mark A. Rothstein, et al, Quarantine and Isolation: Lessons Learned From

SARS, A Report to the Centers for Disease Control and Prevention (November 2003), 16. 

16. Ibid. 

17. Joseph S.M. Peiris, M.D., et al, “The Severe Acute Respiratory Syndrome,” 

New England Journal of Medicine 349, no. 25 (18 December 2003): 2431. 
42 . . . The Impact of Quarantine on Military Operations

18. CDC Public Health Guidance for Community-Level Preparedness and Response

to SARS Version 2, Core Document, 8 January 2004, 4.

19. Rothstein, 5-6. 

20. World Health Organization, Alert, verification and public health management of

SARS in the post-outbreak period, 14 August 2003, 1. 

21. Poh Lian Lim M.D., et al, “Laboratory-Acquired Sever Acute Respiratory

Syndrome,” New England Journal of Medicine 350, no. 17 (22 April 2004): 1746. 

22. Donald E. Low, M.D. and Allison McGeer, M.D., “SARS – One Year Later,” 

New England Journal of Medicine 349, no. 25 (18 December 2003): 2381. 

23. Peiris, 2436. 

24. Low, 2381. 

25. Ibid. 

26. Peiris, 2432. 

27. Rothstein, 67. 

28. CDC Public Health Guidance for Community-Level Preparedness and Response

to SARS Version 2, Core Document, 8 January 2004, 6.

29. Rothstein, 23. 

30. Ibid., 24. 

31. Ibid. 

32. Ibid. 

33. Rothstein, 25. 

34. Ibid. 

35. World Health Organization, Consensus Document on the Epidemiology of

Severe Acute Respiratory Syndrome (SARS), 16-17 May 2003, 13. 

36. Peiris, 2432. 

37. Ibid. 
The Impact of Quarantine on Military Operations . . . 43

38. Sonja J. Olsen et al, “Transmission of the Severe Acute Respiratory Syndrome on

Aircraft,” New England Journal of Medicine 349, no. 25 (18 December 2003): 2416-2422.

39. Rothstein, 66. 

40. Ibid. 

41. Ibid., 68. 

42. Jen Lin-Liu, “Chinese Students Coped with the Isolation of Quarantine,” The 

Chronicle of Higher Education 49, no. 45 (18 July 2003): 33. 

43. Rothstein, 70. 

44. Ibid., 76. 

45. Ibid. 

46. Elena Cherney and Mark Heinzl, “New Virus Caught Toronto Off Guard –

Doctors Race to Get Handle on Illness, Which Landed Before Global Health Alert,” The

Wall Street Journal, 8 April 2003. 

47. Rothstein, 44. 

48. Ibid. 

49. Ibid. 

50. Ibid., 53. 

51. Ibid., 54. 

52. Ibid., 55. 

53. Dahlia Chiche, “A quarantine diary: a doctor finds the experience of being

quarantined far harder than she anticipated,” Medical Post 39, no. 27 (15 July 2003): 37. 

54. Rua Mercier, “Reflections while under SARS quarantine,” Journal of the

Canadian Association of Emergency Physicians 5, no. 4 (July 2003): 235. 

55. Terry Murray, “MD’s Illness have her a unique view of SARS,” Medical Post

39, no. 19 (13 May 2003): 5.

56. Celia Milne, “SARS: A strange time to be a doctor,” Medical Post 39, no. 15

(15 April 2003): 1. 
44 . . . The Impact of Quarantine on Military Operations

57. Cherney, 8. 

58. Rothstein, 59. 

59. Ibid., 77. 

60. Ibid. 

61. Nelson Lee M.D., et al, “A Major Outbreak of Severe Acute Respiratory Syndrome

in Hong Kong,” New England Journal of Medicine 348, no. 20 (15 May 2003): 1986. 

62. Rothstein, 77. 

63. Ibid., 80. 

64. Ibid., 81. 

65. Ibid., 84. 

66. Rothstein, 85. 

67. Ibid. 

68. Lt Col Gregory Chan, “Dealing with an Emerging Infectious Disease: Lessons

Learnt from the SARS Outbreak in Singapore,” PACOM Conference, September 2004. 

69. Rothstein, 85. 

70. Ibid., 89. 

71. Ibid. 

72. Ibid., 90. 

73. Chan, “Dealing with an Emerging Infectious Disease: Lessons Learnt from the

SARS Outbreak in Singapore.” 

74. Rothstein, 91-92. 

75. Ibid., 95. 

76. Rothstein, 97. 

77. Ibid. 

78. Ibid., 101. 
The Impact of Quarantine on Military Operations . . . 45

79. M.L. Lee, et al, “Use of quarantine to prevent transmission of severe acute 

respiratory syndrome-Taiwan, 2003,” JAMA 290, no. 8 (27 August 2003): 1021. 

80. Ibid. 

81. Ibid. 

82. Ibid., 1022. 

83. Antonio Regalado, “The SARS Outbreak: Hospital Lockdown in Taiwan 

Appears to have Backfired – Virus has Spread Rapidly, Prompting U.S. Warning; Days

of Boredom, Terror,” Wall Street Journal, 2 May 2003. 

84. Rothstein, 105. 

85. Ibid. 

86. Brigg Reilley, M.P.H., et al, “SARS and Carlo Urbani,” New England Journal

of Medicine 348, no. 20 (15 May 2003): 1951. 

87. Rothstein, 107. 

88. Reilley, 1951. 

89. Rothstein, 107. 

90. Ibid., 113. 

91. Ibid. 

92. Ibid., 116. 

93. Lieutenant Colonel Stephanie Stephens, “Legal Issues in Consequence

Management,” lecture, Determined Promise 03, October 2004. 

94. Commander’s C-CBRNE Resource, 11. 

95. Stephens, “Legal Issues in Consequence Management.” 

96. Commander’s C-CBRNE Resource, 11. 

97. Ibid. 

98. Elinor Levy and Mark Fischetti, The New Killer Diseases (New York: Crown 

Publishers, 2003), 23.
46 . . . The Impact of Quarantine on Military Operations

99. Ibid. 

100. Lawrence Gostin et al., “The Model State Emergency Health Powers Act,”

JAMA, 7 August 2002, 625. 

101. Ibid., 623. 

102. Ibid., 626. 

103. George Annas, “Bioterrorism, Public Health, and Civil Liberties,” NEJM, 25

April 2002, 1340. 

104. Ibid. 

105. Ibid., 1341. 

106. The Center for Law & the Public’s Health, “Model State Public Health Laws,”

On-line, Internet, 2004, available from http://www.publichealthlaw.net/Tresources/

Modellaws.htm. 

107. Ibid. 

108. Lynette Iezzoni, Influenza 1918 – The Worst Epidemic in American History 

(New York: TV Books, 1999), 17. 

109. Ibid. 

110. Commander’s C-CBRNE Resource, AF/XOS-FC, Bio-Defense State of

Knowledge - Restriction of Movement, November 2004, 7. 

111. Dod Directive (DoDD) 6200.3, Emergency Health Powers on Military

Installations, 12 May 2003, 1.

112. Commander’s C-CBRNE Resource, 9. 

113. Dod Directive (DoDD) 6200.3, 3.

114. Commander’s C-CBRNE Resource, 4. 

115. Ibid. 

116. Richard Hoffman and Jane Norton, “Lessons Learned from a Full-Scale

Bioterrorism Exercise,” CDC Emerging Infectious Diseases, On-line, Internet, Nov-Dec 

2000, available from http://www.cdc.gov/ncidod/eid/vol6no6/hoffman.htm. 

117. Ibid. 
The Impact of Quarantine on Military Operations . . . 47

118. Ibid. 

119. Donald Henderson, Thomas Inglesby, and Tara O’Toole, “A Plague on Your

City: Observations from TOPOFF,” Clinical Infectious Diseases, 29 January 2001, 440.

120. Tara O’Toole, Michael Mair, and Thomas Inglesby, “Shining Light on Dark

Winter,” Clinical Infectious Diseases, 19 February 2002, 972. 

121. Ibid., 980. 

122. Ibid., 978. 

123. Sooner Spring Final Report, Validating Oklahoma Bioterrorism PlanningOklahoma City, OK, 12 April 2002, 3.

124. Ibid., 6. 

125. Ibid., 7. 

126. Commander’s C-CBRNE Resource, 19. 

127. Ibid. 

128. Ibid., 12. 

129. Ibid. 

130. Ibid. 

131. Ibid., 13. 

132. Ibid. 

133. Ibid. 

134. Ken Alibek, Biohazard (New York, NY: Random House, 1999). 

135. Bruce Bennet, “Maintaining Force Flow Despite BW Threats,” unpublished 

lecture, RAND, September 2004. 

136. Ibid. 
48 . . . The Impact of Quarantine on Military Operations
The Impact of Quarantine on Military Operations . . . 49

USAF Counterproliferation Center 

The USAF Counterproliferation Center was established in 1999 to provide 

education and research to the present and future leaders of the USAF, to assist them in 

their activities to counter the threats posed by adversaries equipped with weapons of mass 

destruction 

Barry R. Schneider, Director 

USAF Counterproliferation Center 

325 Chennault Circle

Maxwell AFB AL 36112-6427 

Email: Barry.Schneider@maxwell.af.mil

Jo Ann Eddy, Associate Editor 

The Counterproliferation Papers 

Email: JoAnn.Eddy@maxwell.af.mil

(334) 953-7538 (DSN 493-7538)
50 . . . The Impact of Quarantine on Military Operations